Public Release: 

Quality measures for skilled nursing facilities may not result in better outcomes

The JAMA Network Journals

Among fee-for-service Medicare beneficiaries who received care at a skilled nursing facility following hospital discharge, better performance on various measures of quality of care was not consistently associated with a lower risk of hospital readmission or death at 30 days, according to a study in the October 15 issue of JAMA.

One in five Medicare beneficiaries is readmitted to the hospital within 30 days of discharge. These readmissions are costly and potentially preventable. Skilled nursing facilities (SNFs) represent the most common setting for postacute care in the United States. Little is known about the association between available SNF performance measures and the risk of hospital readmission, according to background information in the article.

Mark D. Neuman, M.D., M.Sc., of the University of Pennsylvania, Philadelphia, and colleagues used national Medicare data on fee-for-service beneficiaries discharged to a SNF after an acute care hospitalization to examine the association between SNF performance on publicly available metrics and the risk of readmission or death 30 days after discharge to a SNF. The metrics were SNF staffing intensity, health deficiencies identified through site inspections, and the percentages of SNF patients with delirium, moderate to severe pain, and new or worsening pressure ulcers.

Of 1,530,824 discharges to SNFs, 321,709 were followed by readmission within 30 days (21.0 percent), and 72,472 were followed by a death within 30 days (4.7 percent). The overall rate of 30-day readmission or death was 23.3 percent. Although better performance on several available SNF performance measures (including better staffing ratings and better facility inspection ratings) was associated with improved outcomes in unadjusted analyses, these associations were diminished substantially after adjustment for patient factors, the discharging hospital, and SNF facility characteristics.

In fully adjusted models, SNFs with better facility inspection ratings demonstrated a slightly lower adjusted risk of readmission or death; however, adjusted outcomes did not vary meaningfully across SNFs that differed in terms of staffing ratings or their performance on clinical measures related to pain or delirium. Other measures did not predict clinically meaningful differences in the adjusted risk of readmission or death.

"Our results provide new information to inform the efforts of hospitals, health systems, and insurers to reduce rates of hospital readmission through more effective use of postacute care. Ultimately, although SNF performance measurement plays an important role in promoting transparency and accountability in the U.S. health care system, our findings suggest that in their current form they are unlikely to serve as a sole basis for large-scale reductions in readmissions unless accompanied by other strategies," the authors write. (doi:10.1001/jama.2014.13513; Available pre-embargo to the media at http://media.jamanetwork.com)

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: What Makes a Good Quality Measure?

In an accompanying editorial, Elizabeth A. McGlynn, Ph.D., and John L. Adams, Ph.D., of the Kasier Permanente Center for Effectiveness and Safety Research, Pasadena, Calif., comment on the two JAMA studies that examined quality indicators.

"Neither study looked at other processes as potential predictors of the outcomes of interest (readmission, death, childbirth outcomes) and therefore missed an opportunity to identify areas for future measure development. Further, careful consideration of the ultimate goal of a quality measure must be made. The information required for consumers to choose among nursing homes or hospitals may be different than the information required to improve clinical outcomes. Measures that work for one purpose and not another are still valuable. Future studies of quality measures should establish a clear framework and expectations for the intended goals of quality measures. Both reports make it clear that a great deal of additional work is needed to achieve the quality measures necessary for a more complete characterization of system performance and potential improvement opportunities." (doi:10.1001/jama.2014.12819; Available pre-embargo to the media at http://media.jamanetwork.com)

Editor's Note: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

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